AAPC-CPC Certified Professional Coder - Set 4 - Part 3

Correct Answer: Initial consultation to decide on surgery

The Medicare manual lists the initial consultation or evaluation by the surgeon to determine the need for surgery as a service not included in the global surgical package. This policy applies only to major surgical procedures. Option a is incorrect because the exclusion applies only to complications that need a return trip to the OR, so this care stays inside the package. Option b is incorrect because routine follow-up care related to recovery is part of the global package, so a separate payment is not made for it. Option d is incorrect because the guidance counts ICU or critical care unit visits made by the surgeon as part of the package, apart from some critical care situations.

Correct Answer: The surgical procedure code only

A physician who performs the surgery and furnishes all usual pre- and postoperative work bills for the global package by entering the appropriate procedure code for the surgical procedure only. Billing visits included in the package is not allowed. Option a is incorrect because visits and other services included in the global package cannot be billed separately by the physician who furnishes the entire package. Option c is incorrect because that modifier identifies a physician who provides only postoperative management after a transfer of care, not one who performs the surgery and all follow-up. Option d is incorrect because the surgical-care-only modifier applies when physicians agree on a transfer of care during the global period, which is not the case for the entire package.

Correct Answer: Teaching physician presence during key or critical portions

Medicare requires the record to show that the teaching physician performed the service or was physically present during the key or critical portions when the resident performed it, along with the teaching physician's participation in patient management. Option a is incorrect because student contributions are limited, since review of systems and past family/social history are taken as part of an E/M service but are not separately billable. Option b is incorrect because the manual requires the teaching physician to perform the service or be present for key portions, so independent completion by the resident does not meet the payment requirement. Option c is incorrect because the manual ties presence to the key or critical portions of the service, and requires presence for the full billed period only for time-based codes.

Correct Answer: Time the teaching physician is physically present

For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. Teaching physician presence, with the resident or alone with the beneficiary, supports the billed time. Option a is incorrect because nurse notes may demonstrate that the teaching physician was present during E/M services, which is a documentation role rather than a source of billable time. Option b is incorrect because medicare guidance directs that resident time in the teaching physician's absence is not added to time spent with the beneficiary. Option d is incorrect because the teaching physician must be present for the billed period, so the resident's time without that presence is excluded from the claimed time.

Correct Answer: Be physically present for the key portions

Residents must complete at least 6 months of a GME approved residency program to furnish billable care without the teaching physician present. For a resident with less time, the teaching physician must be physically present for the critical or key portions. Option b is incorrect because re-documenting history is not the stated requirement for this resident; the guidance calls for physical presence during the critical or key portions of the service. Option c is incorrect because GC applies to services meeting the general presence requirements, while services under the primary care exception carry GE; neither modifier replaces presence for this resident. Option d is incorrect because the exception does not require prior approval; centers instead attest in writing and keep records showing they qualify.

Correct Answer: Insufficient, because both used macros only

Medicare teaching physician rules require customized information from the resident or the teaching physician in addition to the teaching physician's macro. Documentation is insufficient when both the resident and the teaching physician use macros only. Option a is incorrect because a dated, legible signature or identity is one documentation requirement, yet it cannot replace customized information supporting a medical necessity determination. Option b is incorrect because a macro generates predetermined text that is not edited by the user, so it cannot describe the specific services furnished to the specific patient on that date. Option c is incorrect because a secured, password-protected entry makes the teaching physician's macro acceptable, but the note still needs customized information from the resident or teaching physician.

Correct Answer: Benefit Policy Manual, Chapter 15

The Medicare Benefit Policy Manual, Chapter 15, provides coverage policy for telephone services, consultations, patient initiated second opinions and concurrent care. Claims processing chapters point readers there instead of restating coverage rules. Option b is incorrect because that chapter describes billing and payment for radiology services, not coverage policy for visit-type services such as consultations or concurrent care. Option c is incorrect because it outlines billing and payment under the laboratory fee schedule, so it deals with lab payment rather than coverage of these physician services. Option d is incorrect because it gives guidance on completing and submitting Medicare claims, which is a claim-form task and not a statement of coverage policy.

Correct Answer: Confirm the visits

Medicare guidance says to confirm hospital visits where the medical facts do not support the frequency of the physician's visits or in cases of beneficiary complaints. Both triggers are present, so confirmation is directed. Option a is incorrect because the presumption that billed visits were made applies in the absence of evidence to the contrary, and unsupported frequency or a complaint is such evidence. Option b is incorrect because the physician's own entries are described only as possible secondary evidence of less value, so they do not settle the matter here. Option c is incorrect because the guidance directs confirmation of whether visits occurred, and a policy requiring visits describes what should happen rather than showing what did.

Correct Answer: American Medical Association

HCPCS Level I is made up of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association. The AMA also republishes and updates CPT codes annually. Option a is incorrect because HHS delegated its authority over national service definitions, codes, and payment modifiers to CMS, and does not itself maintain Level I. Option b is incorrect because CMS maintains the alpha-numeric codes of HCPCS Level II, including decisions on additions, revisions, and deletions, rather than the numeric codes of Level I. Option d is incorrect because a contractor of this kind is tied to Level III, which holds codes specific to that contractor and not included in Levels I or II.

Correct Answer: HCPCS Level II

HCPCS Level II codes, also called alpha-numeric codes, consist of a single alphabetical letter followed by 4 numeric digits. They identify products, supplies, and services that CPT codes do not include. Option a is incorrect because CPT is HCPCS Level I, maintained by the AMA, and its codes consist of 5 numeric digits with no leading letter. Option c is incorrect because this set is maintained and distributed by the American Dental Association and applies to dental services, not to general medical supplies. Option d is incorrect because NDC is the HIPAA standard for drugs and biologics, maintained and distributed by HHS with drug manufacturers, not for supplies or equipment.